Journal of American Family Physician: Diagnosis and Treatment of Plantar Fasciitis

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Journal of American Family Physician: Diagnosis and Treatment of Plantar Fasciitis


A recent review of the treatment of plantar fasciitis by the Journal of American Family Physician suggested resting, night splints, prefabricated orthotics and NSAIDs are effective treatments with an evidence rating of B. Diagnosis of plantar fasciitis is based on patient history and physical examination findings. Most patients have heel pain and tightness after standing up from bed in the morning or after they have been seated for a prolonged time. Typically, the heel pain will improve with ambulation but could intensify by day’s end if the patient continues to walk or stand for long time.


Risk Factors for Plantar fasciitis:


Excessive foot pronation (pes planus)
Excessive running
High arches (pes cavus)
Leg length discrepancy
Obesity
Prolonged standing/ walking occupation
Sedentary lifestyle
Tightness of Achilles tendon and intrinsic foot muscles


On physical examination, patients may walk with their affected foot in elevated to relieve putting pressure on the heel. Palpation of the medial plantar calcaneal region will elicit a sharp, stabbing pain. Passive ankle/first toe dorsiflexion can cause discomfort in the proximal plantar fascia; it can also assess tightness of the Achilles tendon.

Medial Plantar region of the heel

Medial Plantar region of the heel where most pain is elicited

 

Treatment planning for plantar fasciitis


Rest and analgesics treatments:


A patient directed treatment to relieve plantar fasciitis pain consists of rest, activity modification, ice massage, and acetaminophen or nonsteroidal anti-inflammatory drugs. There are few studies to support the benefit of these individual treatments used alone.


Stretching and Physical therapy modalities:


Multiple physical therapy modalities are used for the management of recalcitrant plantar fasciitis. Most therapies are used in combination; therefore, there is poor evidence on which modality is best. Progressive plantar fascia and intrinsic foot muscle stretching techniques have been shown to reduce plantar fasciitis pain.

Eccentric Stretch used for plantar fasciitis

Eccentric Stretch used for plantar fasciitis

 

Arch supports, heel cups and night splints:

Foot orthotics are commonly recommended for persons with plantar fasciitis to aid in preventing over pronation of the foot and to unload tensile forces on the plantar fascia. There are many different orthotics available, including viscoelastic heel cups, prefabricated longitudinal arch supports, and custom made full length shoe insoles.  A recent met analysis and comparative trial examined the effectiveness of foot orthosis in patients with plantar fasciitis and found that prefabricated and custom foot orthotics can decrease rear foot pain and improve function. A Cochrane review found that custom foot orthotics may not reduce foot pain any more than prefabricated foot orthotics.

night splintadjustable night splintGel heel cups

Night splints prevent plantar fascia contracture by keeping the foot and ankle in a neutral 90 degree position, preventing foot plantar flexion during sleep. Anterior night splints seemed to be better tolerated than posterior night splints.

Supportive arch taping, usually tried during physical therapy, may provide relief in first step heel pain, but is inconsistent for long term plantar fasciitis pain.

foot taping

heel pain night splint Orthotics pain cream plantar fasciitis

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